In April 2008, the Australian Government established the National Preventative Health Taskforce to develop a National Preventative Health Strategy by June 2009.
The Strategy will provide a blueprint for tackling the burden of chronic disease currently caused by obesity, tobacco and excessive consumption of alcohol.
The Taskforce has produced a discussion paper, Australia: the healthiest country by 2020. It presents a wide range of options, some of them contentious, to achieve this ambitious target.
One of the strongest themes to emerge from the Australia 2020 Summit’s health stream was the need to refocus national health policy on prevention.1 Perhaps it was no coincidence that, 2 weeks prior to the Summit, the federal Minister for Health and Ageing, Nicola Roxon, had established the nine-member National Preventative Health Taskforce to develop “a comprehensive and lasting Preventative Health Strategy by mid 2009”.2
* The report is now open for public comment and submissions can be made at http://www.preventativehealth.org.au until 2 January 2009.
In the first instance, the Taskforce was asked to focus on how to reduce harm flowing from obesity, tobacco and alcohol. In October 2008, the Taskforce produced a discussion paper titled Australia: the healthiest country by 2020.* It presents the Taskforce’s preliminary views, based on the best local and international research, on how we might achieve this ambitious goal, particularly related to obesity, tobacco and alcohol. It is backed up by three detailed technical reports: Obesity in Australia: a need for urgent action;3 Tobacco control in Australia: making smoking history;4 and Preventing alcohol-related harm in Australia: a window of opportunity.5
Just as any business would do when planning major changes, the Taskforce is now seeking extensive information from its major stakeholders and conducting national consultations with a wide range of interested national, state and local organisations.
National Preventative Health Taskforce Members
Professor Rob Moodie, Chair
Professor Mike Daube, Deputy Chair
Ms Kate Carnell AO · Dr Christine Connors · Mr Shaun LarkinDr Lyn Roberts AM · Professor Leonie Segal · Dr Linda SelveyProfessor Paul Zimmet AO
Obesity, tobacco and alcohol have been chosen because of the enormous burden of disease for which they are responsible in Australia. Combined with the related risks of physical inactivity, low levels of consumption of fruit and vegetables, high blood pressure and high blood cholesterol, they make up the top seven preventable risk factors that influence the burden of disease. Altogether, these modifiable risk factors account for nearly a third of the burden of disease in Australia.6
Several major concerns have arisen that have underlined the support for preventive action. One is the possibility that unless we halt and reverse the rise of overweight and obesity, we will be granting a poor legacy to succeeding generations of Australians. A recent study by Holman and Smith has shown that trends in overweight and obesity in Australian children predict that their life expectancy will fall 2 years by the time they are 20 years old, setting them back to levels seen for men in 2001 and for women in 1997.7
A second concern is the projected load on the health care system, and the unsustainable financial costs of inaction. The current overall cost to the health care system associated with these three risk factors is in the order of almost $6 billion per year.
Another concern is the realisation that obesity, tobacco and alcohol result in large drains on Australia’s productivity, estimated to be almost $13 billion per year.8,9 In fact, the Health Minister stated that the Rudd Government would
treat preventive health care as a first-order economic challenge ... because failure to do so will have a long-term negative impact on workforce participation, growth in productivity and the overall health budget.10
However, if we can effectively introduce national-scale preventive programs, then, as the World Health Organization estimates, many people could gain an extra 5 years of healthy life, by modifying these preventable risk factors11 — not just more life, but healthy life.
Good prevention works. Fifty years ago, three-quarters of Australian men smoked; now, less than one-fifth of men smoke. As a result, tobacco-related deaths in men have nose-dived from the peak levels seen in the 1970s and 1980s.6 Similarly, deaths from cardiovascular disease have dropped precipitously from all-time highs in the late 1960s and early 1970s. Through sustained and systematic national and state programs, road trauma deaths in Australia have decreased 80% since 1970. Death rates in 2005 were similar to those in the early 1920s.11
Australia’s commitment to improving immunisation levels has resulted in much higher immunisation coverage rates, eliminating measles and resulting in a decrease of nearly 90% in serogroup C meningococcal cases in only 4 years. Reductions in HIV/AIDS and sudden infant death syndrome are other impressive examples of the power of well coordinated and well financed prevention programs.
Not only does good prevention work, it also pays financial dividends. In 2003, the Australian Government Department of Health and Ageing commissioned a study that demonstrated highly impressive long-term returns on investment and cost savings through the preventive action of tobacco control programs, road safety programs and programs preventing cardiovascular disease, measles and HIV/AIDS.12 The report estimated that the 30% decline in smoking between 1975 and 1995 had prevented over 400 000 premature deaths12 and saved costs of over $8.4 billion — more than 50 times greater than the amount spent on antismoking campaigns over that period. Prevention for a healthier America, a 2008 study, reinforces the cost-effectiveness of prevention. It shows that for every US$1 invested in proven community-based disease prevention programs, consisting of increasing physical activity, improving nutrition and reducing smoking levels, the return on investment, over and above the cost of the program, would be US$5.60 within 5 years.13
As a start, the Taskforce’s discussion paper sets some ambitious targets for Australia, if we are indeed to become the healthiest country by 2020.2 These targets are:
Halt and reverse the rise in overweight and obesity
Reduce the prevalence of daily smoking to 9% or less
Reduce the prevalence of harmful drinking for all Australians by 30%
Contribute to the “Close the Gap” target for Indigenous people, to reduce the 17-year life expectancy gap between Indigenous and non-Indigenous people14
The Taskforce presents a number of approaches for debate and discussion. The level of certainty regarding what needs to be done varies between tobacco, alcohol and obesity. For instance, we are very sure about measures needed to get smoking rates down. Similarly, much is known about what needs to be done to reduce the harm caused by alcohol and overweight and obesity; but there is more to be learned. Should we stop because we need more knowledge? The Taskforce is convinced that we must act now on the basis of what we know now, following the best evidence and advice available, and learn by doing. In each of the three areas, there is a need to establish clear national research strategies, build the evidence base, and monitor and evaluate the effectiveness of actions taken.2
In addition to whole-of-population approaches, there is a common need for targeted approaches to obesity, tobacco and alcohol for disadvantaged groups, particularly Indigenous and low-income Australians, pregnant women, and young children.
Shift industry supply and marketing and consumer demand towards healthier products. This can include making changes to the taxation system to provide incentives to increase access to healthier foods and active recreation, and provide disincentives for unhealthy foods, such as increasing taxes for energy-dense foods. It also includes regulating the amount of trans fat, saturated fat, salt and sugar content in foods; regulating food labelling; and providing subsidies for rural and remote area transport of fresh foods.
Protect children from marketing of unhealthy foods and beverages while simultaneously improving public education and information. This includes curbing inappropriate advertising and promotion, such as banning advertising of energy-dense, nutrient-poor foods during children’s television viewing hours.
Widespread implementation of programs in schools, communities and workplaces to ensure that physical activity and healthy eating become part of everyday life. The workplace, in particular, presents huge opportunities for prevention. This results from a conjunction of the rising interest of employers in improving productivity, the interest of the insurance industry in workplace prevention, and the rise of workplace preventive health providers.
Reshape urban environments towards healthy options through consistent town planning, building design and infrastructure investments (eg, for walking, cycling, food supply and recreation).
Strengthen, skill and support primary health care providers to support people in making healthy choices, especially through the delivery of community education and advice about nutrition, physical activity and management of overweight and obesity.
Ensure that cigarettes cost significantly more, as consumption is sensitive to price. Australia has one of the lowest levels of tax on cigarettes as a proportion of total price among Organisation for Economic Co-operation and Development countries.15
Further regulate the tobacco industry with measures such as ending all forms of promotion, including point-of-sale displays, and mandating plain packaging of tobacco products.
Increase the frequency, reach and intensity of education campaigns that personalise the health risks of tobacco. The evidence for the effectiveness of these campaigns is now very strong.
Ensure that all smokers in contact with the Australian health care system are given the strongest and most effective available encouragement and support to quit smoking.
Increase the understanding of how being a non-smoker and smoking cessation can become more “contagious”, so that these processes can be accelerated among less well educated groups and disadvantaged communities.
Manage the physical availability (access) and economic availability (price) of alcohol. The high accessibility of alcohol — in terms of outlet opening hours, density of alcohol outlets and discounting of alcohol products — is a major issue in many Australian communities.
Address the cultural place of alcohol in Australia. Social marketing and public education are required, and would be more effective if the marketing of alcoholic beverages is restricted, including curbing advertising and sponsorship of cultural and sporting events.
Shift manufacturers’ supply towards lower-risk products through changes to the current taxation regime that would stimulate the production, marketing and consumption of low-alcohol products.
Improve enforcement of current legislative and regulatory measures such as Responsible Service of Alcohol, bans on serving intoxicated people and minors, or continuing to lower blood alcohol limits in drink-driving laws.
Strengthen primary health care to help people make healthy choices by supporting brief interventions. Routine practice by trusted health professionals and other health workers in primary health care settings can assist changes in drinking behaviour and attitudes to alcohol consumption.
Develop effective models of safer patterns of alcohol consumption in different communities. This can be done through changes to the cost of alcohol and an understanding of the impact that different types of alcohol outlets and their density have on hospitalisation, violence and crime rates.
It is important to ensure national leadership and coordination. In the Taskforce’s view, a National Prevention Agency (NPA) should be established; such an agency is long overdue. It would take the leadership role, working with different levels of government to ensure the implementation and support of prevention programs nationally. The Agency would support
the coordination of partnerships and interventions, ensuring the relevance and quality of workforce training activities, social marketing, public education and the monitoring and evaluation of interventions. The NPA would consist of a relatively small group of credible leaders in prevention, with a track record and capacity to “make things happen” for preventative health reform.2
Becoming the healthiest nation by 2020 sets us a real challenge. We have deliberately chosen to tap into Australia’s competitive nature. The Taskforce has identified a wide range of options — some of them controversial — that we feel must be considered if we are to produce major reductions in the burden of disease caused by obesity, tobacco and alcohol. To achieve this ambition, prevention must become an essential part of the national infrastructure, not just a short-term project. We will have to engender support not only from federal, state and territory governments but from all parts of the community, be they individuals and families, communities or industry.2
We will have to make some brave decisions, and we must ensure that these reductions are effectively achieved in those with the poorest health — Indigenous Australians, those with the least education and income, and those in rural and remote Australia.
Key imperatives for improving Australia’s health
Shift industry supply and marketing and consumer demand towards healthier products
Regulate the amount of trans fat, saturated fat, salt and sugar content in foods
Protect children from marketing of unhealthy foods and beverages while improving public education and information
Widespread implementation of programs in schools, communities and workplaces
Reshape urban environments towards physical activity and healthy food supply
Strengthen, skill and support primary health care providers
Ensure that cigarettes cost significantly more
Further regulate the tobacco industry
Increase the frequency, reach and intensity of education campaigns
Ensure that all smokers in contact with the Australian health care system are supported to quit smoking
Accelerate quitting among less well educated groups and disadvantaged communities
Manage the physical availability (access) and economic availability (price) of alcohol
Address the cultural place of alcohol in Australia
Shift manufacturers’ supply towards lower-risk products
Improve enforcement of current legislative and regulatory measures
Strengthen primary health care to help people make healthy choices by supporting brief interventions
Develop effective models of safer patterns of alcohol consumption in different communities